A physician-patient meeting usually results in a diagnosis, with the physician writing a prescription for a pharmaceutical drug to treat the patient's diagnosed problem. In writing the prescription, the physician will ideally verify that the pharmaceutical drug is on formulary. The formulary is a list that informs prescribing physicians and pharmacists of the pharmaceuticals for which insurance providers will pay. The formulary may contain brand name or generic pharmaceuticals or both. In this regard, generic pharmaceuticals have the same active ingredients, strength, and dosage as their brand name counterparts, and are therapeutically equivalent to them.
In situations where patients have a chronic condition, such as high blood pressure or high cholesterol, the patient requires medication for a sustained period. An original prescription for a pharmaceutical drug to treat a chronic condition (a chronic medication), may include one or more refills authorizing the pharmacy to dispense additional medication in accordance with the original prescription without further authorization from the prescribing physician. Moreover, patients with chronic conditions often require the physician to re-prescribe or renew prescriptions for chronic medication over time. The original prescription typically contains the patient's name, the pharmaceutical's name, the prescribed dosage, and any renewal or refill information.
The original prescription is typically given to a pharmacy (whether retail, mail-order, on-line, or otherwise) that inputs the prescription information, along with the patient's pharmacy benefits and insurance information, into a computer and checks with the appropriate Pharmacy Benefit Management organization (PBM), or a PBM group at an insurance company, via telephone or on-line computer connection to ensure that the prescribed pharmaceutical drug is on the formulary.
PBMs track the prescriptions written by each physician who has a contracted with one or more of the health care plans affiliated with the PBM. PBMs administer prescription pharmaceutical claims, establish formularies, track physician prescribing patterns, provide education to improve their efficiency and cost effectiveness, and provide disease management programs. PBMs also seek to control the cost of prescription pharmaceuticals.
To lower the costs of prescription pharmaceuticals, PBMs negotiate prices on medications with pharmaceutical manufacturers. PBMs then determine price-performance profiles for every pharmaceutical on the market. Given that different pharmaceutical companies negotiate different prices with pharmaceutical manufacturers, the resulting price-performance profiles necessarily vary. For example, two pharmaceuticals for the treatment of high blood pressure will likely have two different price-performance profiles, each dependent upon the price a PBM pays the pharmaceutical manufacturer for the pharmaceutical.
Depending on its price-performance profile, a PBM will assign a status to each pharmaceutical on that PBM's formulary list. Typically, and by way of example, the statuses will be: preferred, approved, approved with prior authorization by the health insurance provider, available only if dispensed as a generic, and not approved. A pharmaceutical that has no formal status on a formulary or that has a “not approved” status is considered to be “off-formulary.” The status of any particular pharmaceutical will, therefore, determine whether and to what extent a patient's health care plan will pay for the purchase of that pharmaceutical.
In addition to this use of formularies, some health care plans also provide physicians with a monthly pharmaceutical budget, financially penalizing physicians who go over budget and rewarding those physicians who are under budget. This is commonly referred to as “risk sharing” or “risk pooling.”
For any number of reasons, PBMs revise their formularies frequently. As a result, there are often changes to the formulary that the patient and his physician may not be aware of.
Thereafter, the patients might learn of the change only when advised by their pharmacist, or when they collect their prescription medication and notice a difference. Due to this late notice, there is frequently insufficient time to appeal or otherwise respond to the change.
PBMs communicate their formularies to physicians by mailing them binders containing formulary information every three to six months. Each health care plan has its own formulary so a physician may receive as many as one hundred different binders, though twenty to thirty is more typical. The content of the formulary is reinforced by a PBM “detail” force of PBM representatives who visit the physician periodically. Despite possessing the binders and the efforts of the “detail” force, physicians typically have a low compliance with the formularies.
For the most part, PBMs enforce their formularies at the pharmacy. When a patient submits a prescription, the pharmacist uses an on-line system to verify that the medication is listed on the patient's health care plan's formulary. If the medication is on-formulary, the pharmacy dispenses it, generally with a small co-payment by the patient. If it is off-formulary, and the prescribing physician has not authorized a generic substitute or a generic substitute does not exist, the patient either pays for the medication himself or the pharmacist calls the prescribing physician's office to request an alternative. This process is time consuming, and it requires the patient either to wait in the pharmacy or to return at a later time to obtain the medication.
Eventually, a patient with a chronic condition consumes the first supply of the prescribed medication. If the original prescription authorizes re-fills, the pharmacy will dispense a re-fill without further contact or authorization from the prescribing physician, assuming, of course, that the prescribed pharmaceutical remains listed on the formulary. If, however, the prescribed pharmaceutical is no longer listed on the formulary and the physician has not authorized a generic alternative, either the pharmacy must call the physician for a substitute or the patient must pay the full retail price for the off-formulary re-fill of the pharmaceutical (Under California law, PBMs must continue to pay for pharmaceuticals whose formulary status has changed). This process is repeated until the pharmacy dispenses the last authorized re-fill (if any), after which the patient or the pharmacy must contact the physician for a prescription renewal.
A renewal or re-prescription is a new prescription based at least in part upon the original prescription, i.e. for a pharmaceutical drug in the same therapeutic category (often the identical pharmaceutical drug), requiring a new authorization from the physician. While based on the therapeutic category of the pharmaceutical drug in the original prescription, the renewal prescription may change based upon revisions to the patient's insurance company's list of approved medications (the “formulary”), the patient's condition at the time of the renewal, or other factors.
Typically, a physician will have many patients with chronic health problems that require “chronic medications” (approximately 44%). As a result, substantial point-of-care inefficiencies arise in refilling and renewing prescriptions for chronic medications. Thus, on any given day, a physician will receive multiple calls requesting authorization for substitute pharmaceuticals that have changed formulary status in a re-fill or renewal situation. In the re-fill situation, the physician must take the time to determine an appropriate substitute that is on-formulary. In the renewal situation, the physician must take the time to evaluate several issues before authorizing a new prescription, namely: (1) whether the patient should continue taking the chronic medication; (2) whether to change any of the parameters of the prescription, e.g. brand or dosages; and/or (3) whether the chronic medication remains on-formulary and if not to identify a therapeutically equivalent pharmaceutical that is on-formulary.
In each case, the prescribing physician must deal with the inefficiencies attendant with the original prescription process, such as looking up the formulary status, dealing with a hard-copy of outdated formularies, reviewing the patient's records, etc. Additionally, because prescribing physicians typically must perform these duties at or very near the time of the pharmacy's telephone call, they are unable to address these issues efficiently, such as by addressing them in batches, verifying that a pharmaceutical is “preferred” by the PBM, etc.
These problems in dealing with formularies generate significant inefficiencies for the physician, and this translates into difficulties for PBMs seeking to control the costs for re-fill and renewal prescriptions. For example, physicians having to make rushed decisions when phoned for renewals are likely to default to the same chronic medication without checking the formulary to see if a different medication is now preferred by the PBM. Even if a chronic medication remains on-formulary, this is nonetheless a missed opportunity for a PBM to communicate its preferences to the prescribing physician because the physician has simply defaulted to the previously prescribed chronic medication without consulting the formulary list.
Preferred pharmaceuticals exist where PMBs have worked out special pricing or similar arrangements with pharmaceutical manufacturers. Therefore, despite the presence of more than a single medication on the formulary, PBMs might prefer one pharmaceutical over another. Even prescribing physicians who check the formulary are likely only to verify that the pharmaceutical is on-formulary, without determining whether that pharmaceutical is preferred by the PBM. Similarly, in the case of re-fills, a prescribing physician forced to determine an equivalent chronic medication that is on-formulary is not likely to determine whether a specific on-formulary pharmaceutical is preferred by the PBM over another therapeutically equivalent pharmaceutical.
Prescribing physicians have the responsibility to care for their patients, and, ultimately, they want to have more control over the decisions relating to their patient's care. PBMs and their formularies represent an intrusion into physicians' decision making processes and generate animosity among the physician community. As a result of this animosity, physicians are resistant to becoming more cooperative and compliant with the PBMs. This animosity, reluctance to comply with PBMs, and the missed communication opportunities between the PBMs and the prescribing physicians reduces compliance with formularies and decreases PBMs' flexibility to have more dynamic, cost efficient formularies.
Accordingly, there is a need in the art to increase the efficiency of using formularies at the point-of-care with a concomitant reduction of the intrusion in the decision-making process. Any improvement in the efficiency of the renewal prescription process would greatly assist in improving the overall efficiency of the prescription process as a whole. To this end, there is a need in the art for a system and/or method that will increase a physician's efficiency in handling renewal and/or refill prescriptions, especially for chronic medications.